Frequently Asked Questions About Filing ERISA Disability Claims

Filing an ERISA Disability claim under an ERISA (Employee Retirement Income Security Act of 1974)-qualified policy can be complicated. Although every employer-provided long-term disability plan must comply with ERISA, the law allows a wide range of flexibility in participant requirements. (An employee insured by an ERISA policy is called a “plan participant.”) To collect any compensation from your policy, you will need to provide significant evidence to support your ERISA disability claim. Your insurance company may deny your claim if you do not provide enough evidence.

In order to quickly and efficiently deal with an ERISA disability claim, you should contact an experienced disability attorney. Our lawyers at Uscher, Quiat, Uscher & Russo, P.C., will guide you through the complex process and help you collect the evidence necessary to have your claim successfully processed.

 What Do You Have To Prove?

Although every ERISA disability insurance policy is slightly different, you must prove to any insurance company that you are disabled. You must be able to prove all of the following with objective evidence:

• The date you became disabled.
• The last date you worked (LDW).
• You have a medical condition that results in disability.
• You are unable to perform the duties of your job.

You must show each of these elements with objective proof. Objective proof is based on facts, observation, and measurement. This is different than subjective proof, such as a personal description of your symptoms. Although you will be required to tell your doctor about your subjective symptoms, the insurance company is primarily interested in objective tests and other evidence.

Proving Disability Date And Last Date Worked

Your doctor and employer should keep records of relevant dates; however, it is your responsibility to obtain those records for the insurance company. You can prove the onset of your disability by providing doctor’s office notes indicating a specific date at which your doctor concluded that your condition became so severe that you could no longer work. If you do not have such specific records, you may have to prove with other objective evidence that you were unable to work as of a certain date.

The last date you worked will be recorded by your employer. You may have access to those records through your human resources department or through your immediate supervisor. If the date does not match your onset of disability date, you may have to provide additional evidence to your insurance company regarding why your last date worked differs.

Medical Evidence

To prove the date you became disabled and the medical conditions that resulted in disability, you must have objective medical evidence. Every insurance company will evaluate that evidence differently; however, there are some generally accepted tests and observable factual evidence that are universally accepted.

In general, any of the following are accepted as objective medical evidence:

• Radiological tests (x-rays, CAT scans, MRIs).
• Nerve conduction tests.
• Blood tests and other laboratory analyses.
• Biopsies.
• Psychological tests conducted by licensed psychologists and psychiatrists.

Often, office notes from doctors are not sufficient objective medical evidence. Doctors document your subjective complaints and take those into account to treat you. However, your insurance company will not consider subjective evidence or medical evidence that is based on subjective complaints. You must have a record of objective evidence in order to prove that you are disabled.

If you do not have enough objective medical evidence, your insurance company may deny your claim or send you to another doctor. If you are sent to another doctor for an independent medical evaluation (IME), you must be completely honest about your conditions. The doctor will likely conduct several tests and collect subjective data as well. The doctor will evaluate whether he or she thinks you are malingering or exaggerating your conditions. The IME performed by the doctor will provide some of the most influential medical evidence to your insurance company, so it is essential that you attend and participate fully in the evaluation.

Vocational Evidence

In order to prove your last date worked and that you are unable to perform job duties, you must provide your insurance company with vocational evidence. Vocational evidence may be obtained from your employer, industry standards, witness statements, and doctors. Your employer can easily provide information regarding your last date worked and a description of your job duties. Once those duties are established, it is your responsibility to prove that you are unable to perform them. If the duties provided by your employer are not complete, you may need to supplement your actual job description with industry standards.

Your doctor can provide an assessment of your functional capacity in order to show that you are unable to perform your job duties. Some of the objective medical tests that your doctor performs can be utilized to show that you are incapable of performing job duties. However, your doctor may also complete a functional capacity evaluation form, which can be provided by your insurance company, to fully describe your abilities and inabilities.

FAQs Regarding ERISA Disability Plans

Many people associate ERISA with retirement plans but it also applies to other employer-provided benefits, including your employer-provided life and health group disability insurance. Here disability lawyers in New York and New Jersey answer some of your frequently asked questions regarding ERISA disability life and health insurance.

What is ERISA?

The Employee Retirement Income Security Act of 1974, or ERISA, is a complicated federal law governing benefits offered by private employers.  ERISA establishes minimum standards for retirement, health, life insurance, disability insurance, and other employee welfare benefit plans.  ERISA does not require employers to provide benefit plans but sets standards for those private employers who do.

ERISA does not govern independently purchased retirement or insurance plans.  Nor does it apply to employee benefit plans offered to government employees (local, state or federal), or the employees of churches or other religious entities.

What Is An ERISA Disability Plan?

ERISA disability life and health insurance policies, are referred to as “plans.” An employee insured by an ERISA disability life or health insurance plan is referred to as a plan “participant” or “beneficiary.”

How can I find out what benefits my ERISA disability plans provides?

You can refer to your Summary Plan Description (SPD), which ERISA requires your plan administer to give you.  The SPD will detail:

• How your plan works.
• What benefits your plan provides.
• What you must do to qualify for benefits.
• How benefits are calculated.
• How to submit a claim.
• How to appeal if your claim is denied.
• Reasons why your benefits could be forfeited or reduced.

In addition to the SPD, you may also have received a booklet describing the procedures for submitting a claim in detail.

You may submit a written request to the plan administrator for a copy of the SPD if you do not already have one. You should keep a record of all communications you have with the plan administrator.

Although SPDs are important, employees must look to the underlying insurance plan or policy itself. If there is a conflict between the SPD and the plan or policy, it is the plan or policy which will control.

If I make a claim, who decides if I am disabled?

ERISA plan administrators and claim administrators are typically large insurance companies, are in charge of ERISA insurance plans. They decide whether a participant is disabled and entitled to receive benefits. Thus, when you seek disability insurance benefits under your employer-provided policy, you must file your claim with the claim administrator. The claim administrator will review your submission and supporting evidence, and then determine whether you qualify for benefits. If you are denied benefits and you file an appeal, the claim administrator will review your appeal and, again, determine whether you qualify for benefits.

How do I file an ERISA disability claim?

Review your plan, policy, SPD or the booklet that you may have received with it to learn about the claims procedure. Their documents explain who is eligible for disability benefits and what standards must be met to receive benefits. They also describe the time limits for making a claim, the information that should accompany the claim, and the address to which the claim materials should be sent.

Consider getting a disability attorney involved from the very beginning before you file your claim and even before you stop working. It is crucial that you meet the deadlines and provide all information requested by the plan administrator. An attorney can collaborate with your treating physicians to ensure that your claim is well supported by medical evidence and is as strong as possible.

What are my rights if my claim is denied?

You are entitled to a written explanation from the claim administrator of the reasons why your claim for disability benefits was denied. You are further entitled to appeal the denial to the claim administrator. If you have not hired a disability attorney by this point, now is the time to do it. You are allowed to submit additional evidence with your appeal. This evidence might include further medical and vocational testing and evaluation. An attorney can review your denial letter and assess the reasons why your claim was denied. He or she can then help you assemble the additional evidence that responds to the claim administrator’s concerns.

It is very important to appeal. If you do not submit an appeal to the ERISA plan administrator, you will likely be barred from taking your claim to court.

If your appeal is denied, you may then bring a lawsuit in federal court.  Unlike other lawsuits, you will probably not have a chance to testify and the court will not allow you to submit any new evidence. It will base its decision on the materials that are already in your claims file. Thus, the importance of submitting complete and thorough documentation supporting your disability claim to the insurance company during the administrative stages (initial filing and subsequent appeal) cannot be overstated.

Oftentimes legitimate life on disability claims has been lost where claimants fail to put their “best foot forward” during the administrative appeal process and are barred from doing so once a lawsuit has been filed. The takeaway: until you have to go to court DO NOT wait to hire an experienced  ERISA disability lawyer – by then it may very well be too late.  These claims are typically won or lost at the administrative appeal level, so this is the time to have the benefit of experienced ERISA counsel.

What impact does ERISA have on disability claims?

Although ERISA was intended to protect your rights and benefits, ERISA’s complicated requirements make it difficult for employees to successfully claim benefits. In practice, ERISA ends up protecting the insurers rather than the employees because if you do not exactly follow the instructions to file a claim for benefits, and if you do not abide by the strict timeline, then your claim could be denied. Further, you may only appeal a denial of benefits to a court after you have exhausted all of your administrative remedies (i.e., made your initial claim and appeal) and court review is limited.

As mentioned above, the court will generally consider only the evidence already in your claims file. In deciding your case, the court will determine whether the insurer “abused its discretion” or acted “arbitrarily.” This means that unless the insurance company’s decision to deny your benefits is unsupported by the evidence or is clearly incorrect, the judge cannot overturn the decision, even if the judge believes that you are really disabled.

In contrast, if you had a private disability policy not covered by ERISA, the court and a jury would review your case “de novo,” or anew and make an independent decision on whether you are disabled.

Disability Lawyers in New York And New Jersey Can Make a Difference

Whether you are applying or appealing a denial for short-term or long-term ERISA disability insurance, our disability lawyers will:

• Obtain and review your medical and employment records to determine the date of your disability and last day of work.
• Ensure your medical and employment records, and other supporting documentation, are complete.
• Ensure you meet all deadlines.
• Review your disability insurance policy to follow filing instructions exactly.
• Compile your supporting documents and application or appeal in a persuasive, thorough and complete package.

Consult the knowledgeable disability lawyers in New York and New Jersey with Uscher, Quiat, Uscher & Russo, P.C., at 201-781-5645 or send an email to discuss your ERISA disability application or appeal.